Transcript Document
Ageing beyond frailty: palliative care and the oldest old Prof. Cees M Hertogh, MD,PhD Elderly Care Medicine & Geriatric Ethics EMGO Institute for Health and Care Research Eos and Tithonos • The ambivalent ideal of aging The transformation of health and illness • Three era’s since 1900: – Infectious disease – Chronic disease – ‘Senescence-process’ Compression of morbidity paradigm: “A new syllogism for aging” •1. natural life span is relatively fixed •2. the age of first appearance of aging manifestations and and chronic symptoms can increase more rapidly than life expectancy •3. therefore the duration of morbidity and disability will decrease • (James F. Fries, 1980, 2011) Explanations and policy implications • Early detection and ‘medicalization’ of chronic disease • Patient education and life style approaches • Investment in ‘plasticity’ of ageing • (Function-enhancing medical interventions) • (improvements in built environment) ‘rectangularization’ of the survival curve Grimley Evans on healthy old age: • By delaying the onset of disabling diseases to later ages when intrinsic aging has raised fatality by reducing adaptability, the average duration of disability before death will be shortened. • In brief: we shall spend a longer time living and a shorter time dying Grimley Evans on healthy old age: • By delaying the onset of disabling diseases to later ages when intrinsic aging has raised fatality by reducing adaptability, the average duration of disability before death will be shortened. • In brief: we shall spend a longer time living and a shorter time dying Intrinsic ageing • ‘homoeostenosis’ : • The progressive narrowing of the capacity to adapt through loss of reserve power • ‘natural death’ : • quality of host resistance > nature of insult to equilibrium Frailty: a controversial concept • Multiple conceptualizations! Frailty: a controversial concept • Multiple conceptualizations! – Transition from service-directed concept (70’s) – To ‘interventionist’ concept (90’s) Federal council on aging (USA): • Persons, usually but not always over the age of 75, who because of an accumulation of various continuing problems often require one or several supportive services in order to cope with daily life • (FCA, 1978) • Frailty = Chronic disease = Disability Frailty: a controversial concept • Multiple conceptualizations! – Transition from service-directed concept (70’s) – To ‘interventionist’ concept (90’s) • ‘narrow’ biomedical concept » Frailty phenotype (Fried) » State variable (frailty index) (Rockwood) • ‘broad’ epidemiological concept (Deeg, SCP, TFI) Frailty according to the SCP: • A heuristic term to identify risk groups • A process involving the accumulation of physical, psychological and/or social deficits in functioning which increase the risk of adverse health outcomes (functional impairments, admission to an institution, death) Frailty according to the SCP: • A heuristic term to identify risk groups • A process involving the accumulation of physical, psychological and/or social deficits in functioning which increase the risk of adverse health outcomes (functional impairments, admission to an institution, death) • Frailty as a transitional state between the third and the fourth age The fourth age • Laslett: – a period of decline and decrepitude (> 85) • Gilleard & Higgs: – Ageing without agency – the ‘black hole’ of old age • Baltes & Smith: – Person-based – Population-based Recent news from gerontology… • The good news: the third age (young old) • Increase in life expectancy: more people live longer • Substantial latent potential for better fittness in old age • Succesive cohorts show gains in physical and mental fitness • Evidence of cognitive-emotional reserves of the aging mind • More and more people age succesfully • High levels of emotional and personal well-being (selfplasticity) • Effective strategies to master the gains and losses of late life Recent news from gerontology… • The not-so-good or bad news: the fourth age (oldest old) • Sizeable losses in cognitive potential and ability to learn • Increase in chronic stress syndrome • Sizeable prevalence of dementia (about 50% in 90-yearolds) • High levels of frailty, dysfunctionality and multimorbidity • Dying at older ages: with human dignity? • prospects for the 21st century: the era of chronic incompleteness of mind and body? • (Baltes & Smith, BASE) Geriatric palliative care “Concentrating on diagnosing the disease for which often little can be done will lead to ignoring symptoms and disabilites for which often much can be done” (Tinetti) Palliative medicine Elderly care medicine Two radical notions converge, each expanding the scope and invigorating the other (Cassell) Illness trajectories Geriatric palliative care • An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness – (WHO, new) • Integral multidisciplinary care for patients with incurable diseases, aimed at reaching and maintaining optimal quality of life for both patients and their relatives. – (WHO, old) • The medical care and management of older patients with healthrelated problems and progressive, advanced disease for which the prognosis is limited and the focus of care is quality of life – (EUGMS, 2007) Domains relevant for GPC • Pain and symptom management • (Functional) autonomy and QoL • Psycho-social needs and meaning • Advance care planning and medical decisionmaking • Supportive care for carers Our research: dementia & stroke • Pain and symptom management – Dementia: pain and problem behaviour – Dementia: pneumonia in the last stage of life Our research • (Functional) autonomy and QoL – Care needs of elderly chronic stroke patients (CASTILON) – Dementia: (electronic) alternatives for restraint use Our research • Psychosocial needs and meaning – Spiritual end of life care in nursing homes – ‘succesful’ old in deep old age: the patient’s perspective Our research • Advance care planning and medical decision making – Role of advance directives (for euthanasia) in dementia caregiving – Early palliative care in dementia caregiving – Advanced dementia: an aid to decision-making – Thoughts on the future: the perspective of dementia patients – Palliative care following acute stroke: a guide to decision making Our research • Supportive care for carers – Advanced dementia: an aid to decision-making – Care needs of chronic stroke patients (CASTILON) Do not go gentle into that good night. Old age should burn and rave at close of day; Rage, rage against the dying of the light Dylan Thomas